Twelve tips for assessing and managing mild cognitive impairment and major neurocognitive disorder in older people

Assessing and managing older patients with mild cognitive impairment and dementia (classified as major neurocognitive disorder in DSM-5) can be challenging. A comprehensive literature review provides support for 12 practical and evidence-informed tips: (1) Cognitive testing should be routine when assessing older patients, although an abnormal result is not necessarily diagnostic of cognitive impairment or dementia, especially in the presence of delirium. (2) The cognitive test chosen should be based on the patient's functional status. (3) Brain imaging is recommended in a number of clinical situations according to commonly accepted guidelines but is not necessary in all cases. (4) Comprehensive geriatric assessment can add value if the cognitive diagnosis is unclear or geriatric syndromes are present. (5) Medical treatment of modifiable vascular risk factors for mild cognitive impairment and major neurocognitive disorder should be optimized. (6) Cholinesterase inhibitors should be considered as first-line pharmacotherapy in patients with the diagnosis of major neurocognitive disorder. (7) A baseline electrocardiogram should be obtained before a patient commences cholinesterase inhibitor therapy. (8) Antipsychotic medications should not be used routinely in dementia care, and nonpharmacological approaches should be considered when managing behavioral and psychological symptoms of dementia. (9) Monitoring disease progression and response to treatment should be part of dementia care. (10) Safety concerns should be addressed with the involvement of other professionals. (11) A goals-of-care discussion should be part of dementia care. (12) The impact of stress on care providers should be assessed routinely and managed proactively.